Firehouse Wednesday Release Form

Registration and Liability Release form for Kern Park Christian Church for the

Jr. & Sr. Hi. Event: Fire House Wednesday St. Johns Christian Church — December 5, 2007 NAME/S:___________________________________________________________________________________ ADDRESS:___________________________________ PHONE:_____________________ CITY: _________________ STATE:_________ ZIP CODE: _______________ Person to notify in emergency:__________________________ Phone (if different than above)_____________________ COMMENTS OR MEDICAL INFO (Please, list all medications, allergies, medical conditions : _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ INSURANCE COMPANY:_______________________________________POLICY #:___________________ In the event of an emergency where medical treatment is required I give my permission to the Church staff or sponsor to obtain the services of a licensed physician and I hereby authorize medical treatment. Please notify me immediately concerning any such emergency. I the parent/guardian of the above named student/s, give my permission and authorization is hereby given to ride in church furnished transportation and
consent
do not consent to the use of any video images, photographs, audio recordings, or any other visual or audio reproduction that may be taken of the subject of this release during the activity/event to be used, distributed, or shown as Kern Park Christian Church deems necessary. I the parent/guardian of the above named student/s, DO HEREBY RELEASE KERN PARK CHRISTIAN CHURCH, their staff and officers from any responsibility in case of accident, illness, or injury during his/her attendance. Parent/Guardian Signature ________________________________ Date_______________________ Parent/Guardian Printed Name ________________________________

Please Tear off lower portion and Keep

Jr. & Sr. Hi. Event: Fire House Wednesday December 5, 2007 Location: St. Johns Christian Church 8044 N. Richmond Ave Portland, OR 97203 Emergency Contact: Brent Parker Cell # 503-679-2960

Meet at Church at 5:30pm and will return by 8:30pm